PPO Adjustments

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slcdentist
Posts: 2
Joined: Thu May 25, 2017 3:40 pm

PPO Adjustments

Post by slcdentist » Thu May 25, 2017 4:32 pm

We participate with some insurance plans that allow us to bill our standard fee rather than the PPO fee if the annual maximum has been exceeded. Is there a way for Open Dental to automate this process so that when the maximum has been met the PPO fee schedule is no longer used until the maximum resets? Currently we have to do this manually, and many times it is missed.

Thanks.

rhaber123
Posts: 415
Joined: Fri Dec 11, 2009 12:09 pm

Re: PPO Adjustments

Post by rhaber123 » Thu May 25, 2017 10:16 pm

With ALL insurance plans, including PPO Percentage plan , we always bill our full fees and Open dental automatically calculates the writeoffs for the claims, if you entered that insurance fee schedule in Open Dental. We always submit our office regular fees and never the insurance reduced fees
http://opendental.com/manual/planppo.html

slcdentist
Posts: 2
Joined: Thu May 25, 2017 3:40 pm

Re: PPO Adjustments

Post by slcdentist » Fri May 26, 2017 8:49 am

We always submit our full fee too, and the patients co-payment is estimated by Full fee - PPO Fee Difference X % not covered by insurance. But some plans do not require the PPO fee to honored if the service will not be covered (the patient's maximum has been met). In those cases, I'd like the treatment plan to just show the full fee without any adjustments. Just wondering if that can be automated?

boboffice
Posts: 89
Joined: Sun Mar 29, 2009 7:11 am
Location: Poway, San Diego County, CA

Re: PPO Adjustments

Post by boboffice » Fri May 26, 2017 6:35 pm

I'm not sure how to answer your question, but it brings up another (non-OD) question: Are you sure about this??? Here in CA (and in most states that allow UCR billing for non covered procedures), the max and frequency are NOT reasons to go to UCR. Be careful if you are indeed in such a situation in your state... if you violate these very specific rules you will invite a very painful audit that a colleague of mine just experienced.

The law is here: http://leginfo.legislature.ca.gov/faces ... 0100AB2275

...and the pertinent section: (d) For purposes of this section, “covered services” or “covered dental services” means dental care services for which the plan is obligated to pay pursuant to an enrollee’s plan contract, or for which the plan would be obligated to pay pursuant to an enrollee’s plan contract but for the application of contractual limitations such as deductibles, copayments, coinsurance, waiting periods, annual or lifetime maximums, frequency limitations, or alternative benefit payments.

Just watching out for a fellow OD user!
Robert Marcus DMD
Univ. of CT '93
Poway, CA

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